Constipation in children

What is Constipation?

Constipation can be defined as:

• More than three days between bowel movements

• Stools that are large, hard and painful to pass

• Incomplete bowel movements and stool backs up in the bowel despite daily bowel movements

Many children have constipation at one time or another. Minor changes in daily routine may cause it. Being away from home, changes in eating, drinking or activity may cause constipation. It is very common for children to avoid having a bowel movement at school, which can lead to constipation. Most of these things will not last long. They are easy to correct and do not result in long-term health problems.

Chronic constipation usually develops over months or years. Most children need at least six months of therapy and having regular bowel movements before they can be weaned from the therapy without a relapse. Changes in routine that can cause relapse include travel, change in diet or the start of school. These “slips and setbacks” can be taken care of more easily if they are dealt with promptly. They should not be seen as failed therapy.

Constipation Can be Linked to:

• Stomach aches

• Decreased appetite or eating

• Feeling of being “full”

• Small amounts of blood on the toilet paper or on the outside of the stool

• Stool leaking into the underwear (encopresis or soiling)

• Repeated urinary tract infections

Constipation Does Not Cause:

• Headaches

• Bad breath

• Learning problems

• Back-up of poisons into the bloodstream

• Rupture of the colon or intestine

What are the Symptoms of Constipation?

Children who have chronic constipation gradually develop a stretched rectum. The stretched rectum then becomes filled with a stool plug. Over time the stretched muscles of the rectum cannot push all of the stool out of the rectum. Liquid stool seeps down around this stool plug and can seep out onto the underwear without the child being aware that there is stool in the rectum or that they are about to soil. This is frustrating and embarrassing for both the child and the family. While treatment can help the child solve the problem, it is a chronic condition that has taken time to develop and will take time to correct. Relapse often occurs if treatment is stopped too soon or withdrawn too quickly.

Chronic constipation (lasting over a long period of time) is not usually caused by medical problems. A “blockage” in the colon does not cause it either.

Toddlers often try to hold in their stool after having a painful bowel movement. They often cross their legs and become rigid. They are determined not to have another painful experience and can often hold their bowel movements for days. This, of course, leads to large, hard bowel movements. This experience convinces them that having a bowel movement is something to be avoided. They may sometimes seem to be trying to have a bowel movement when they are actually trying not to go. Fissures and other painful conditions of the anus can also lead to this problem.

Children who are going through toilet training may not want to take the time out from play to go to have a bowel movement. They may also be afraid to use a bathroom other than the one they are used to. Many children do not want to have a bowel movement at school or a new daycare. If you anticipate these problems and deal with them early, you can help resolve the constipation that results from holding in stool in these situations.

Some children have trouble learning to relax their bottom as they try to push stool out. These children may push and hold at the same time, making it difficult to pass stool. Children usually can’t hold in stool and blow at the same time. Having a child blow a pinwheel or party noisemaker while trying to stool can help them learn to relax their bottom.

Some children have slow movement of their colon. This gives the colon more time to remove water from the stool, making it hard, dry and difficult to pass. This may improve with time.

How is Constipation Treated?

Treatment for constipation and soiling has three phases – clean out, maintenance, and reestablishing toileting behaviors.

Clean-Out Phase

The clean-out phase is designed to clear the stool plug out of the colon. This can be done with medicines taken by mouth, enemas and suppositories given in the rectum, or a combination of both. Small children who have holding behaviors because of painful bowel movements or fear of passing stools may do better with medicines given by mouth. Although gentle enemas are effective, they may make the child even more fearful.

Hard stool is very difficult and painful to pass. Your child’s clean-out phase may be started with large doses of mineral oil to soften the stool. Mineral oil is not absorbed and gradually seeps through the hard stool and softens it. It may take several days of mineral oil to soften a large amount of packed stool. Mineral oil is dangerous only if it gets in the lungs. This is why it should not be given to infants or children who have trouble swallowing. Mineral oil can be given by enema or by mouth. Since mineral oil has an oily feel to it, most children will take it better when it is mixed with another food. Some of the easier ways to give it include putting it in milk shakes, pudding, applesauce, ice cream, chocolate milk and in juice “slushies.”

Once your child’s stool is soft, your doctor or nurse practitioner may suggest that you add other medicines by mouth or rectum. It is very important to remove the entire stool plug during the clean-out phase or the next phase will not work as well.

Your child should be on enough medicine to prevent a stool plug from forming. Children on the proper therapy usually have one to three loose to very soft stools every day. If children on therapy go two to three days without a bowel movement, their therapy should be increased. Soiling usually means a stool plug rather than too much medicine.

Maintenance Phase

Once the clean-out phase is complete, your doctor or nurse practitioner will tell you what medicine your child will take every day. Small children who are afraid of painful bowel movements will receive medicine to soften their stool. Mineral oil is very effective for this, because it helps the stool slide out more easily. Fiber, which helps keep water in the stool, may also help wit this. The richest source of fiber is usually found in breakfast cereal. To find how many grams of fiber your child needs each day, add 5 to your child’s age. For example, a 3-year-old child needs about 8 grams of fiber every day.

Some laxatives are salts that hold water in the stool. Examples include Milk of Magnesia and Miralax. Other laxatives work by fermenting sugars and producing gas. These include apple juice, lactulose and maltsupex. These are not very good treatments, because they may cause gas cramps. Other laxatives may cause stretched and weakened muscles to contract. These include senna and bisacodyl. Your doctor or nurse practitioner can suggest the treatment that will work best for your child.

Mild constipation may be treated with diet changes. Increased fiber may soften stools. Sugary drinks that ferment (such as apple and fruit juice) may be used as well. Prune juice has the advantage of fiber as well as natural senna. Extra water or fluids generally don’t reach the colon.

Children with soiling or more severe constipation usually require medication. However, making changes in your child’s diet at the same time may help wean them from medications more quickly. Getting children, especially toddlers, to eat the diet we would like may be difficult, but the extra effort will be rewarded with happier children.

This chart lists some of the pros and cons of various treatments:

Medication Action Advantages Problems

Mineral Oil Lubricates Cheap; stools easy to pass Do not use with infants; Oily Feel

Milk of MagnesiaTM Holds Water Cheap; stools easy to pass Taste

Senna Stimulates Strengthens muscle May cause cramps

Bisacodyl Stimulates Strengthens muscle May cause cramps

Maltsupex Produces Gas None Cost

Lactulose Produces Gas None Cost

MiralaxTM Holds Water No taste Cost

Treatments That Should NOT be Used in Children:

• Fleets Phospho-Soda enemas should not be used in children. They can severely disturb electrolyte balance when held in the colon.

• Milk and molasses or a lactulose enema can cause a distended (puffed out) belly above a stool plug with possible tearing. Therefore, these are not recommended for children with chronic constipation.

Reestablishing Regular Toileting Behaviours

Once your child is having soft, comfortable bowel movements on a regular basis, the next step is to get their regular toileting schedule back on track. Many times, this routine has been disrupted due to the child’s fear of having a painful bowel movement, or because they are less likely to sense when they need to use the toilet for a bowel movement.

Our team at Happy Kids !!! includes specialists who provide additional care for patients with encopresis. These specialists help your child:

• Get a regular toileting routine started

• Have less anxiety around having a bowel movement

• Reduce their stool withholding behaviour

• Have less conflict with their parents over the problem

• Feel that they are part of the treatment team

What is a Normal Stool Pattern at Different Ages?

The stool pattern varies with the age and diet of the child. Infants who are breast-fed may vary from several watery or loose stools a day to going up to 10 days without a stool. By one- to three-months of age, their stools often become pasty and less frequent. Formula-fed infants often have pasty stools one to three times a day. Some formulas such as Carnation Good Start, Nutramigen, Pregestimil and Alimentum may cause loose stools. By 1 year of age, most children are passing formed stools at least once every one to three days.

Infants commonly cry, fuss, turn red and appear to be working hard for several minutes when passing either stool or gas. If the infant is growing well and the physical examination is normal, this is most likely a behavior pattern and not a disease. This will improve as the infant “learns.”

Toddlers and children normally pass stools from three times a day to every three days. The form and color of their stools may vary from day to day. Changes in the color of the stool (unless it is red, black or white) do not mean there is a problem. It just means that the normal colon bacteria are acting on various food dyes. Sometimes even red, black or white stools can just be a result of what the child has been eating or drinking, such as a lot of red juices or jello.

Digestion starts in the stomach where food is mixed with digestive juices. Food slowly leaves the stomach and passes into the small intestine where it is mixed with more fluid. It then passes into the colon as a watery liquid after nutrients have been absorbed. The job of the colon is to slowly absorb water. Soft, formed stool enters the rectum and stretches it, giving the urge to have a bowel movement. To have a bowel movement, we must consciously relax the muscles that are holding the stool in and then push the stool out.

If the child holds back stool or cannot have a bowel movement over several days, the rectum fills up with stool. Over time this stretches the muscles of the rectum and makes them less able to push out stool. The child looses the urge to pass a bowel movement. Holding stool in the rectum also allows more time for water to be removed. This can make the stool hard, dry and painful to pass.

Constipation (con-sti-PA-shun) is common in children but can worry parents. A constipated child has problems moving their bowels (BMs or pooping), do not have BMs often enough, or the stool (poop) is hard or dry. It is rarely caused by a medical condition that the child was born with or by a problem digesting food.

• Common causes are:

o no regular habit of having a bowel movement (BM or pooping)

o starting toilet training too early

o holding the poop in. A child holds the poop in because they are afraid it will hurt to have a BM. It may be too large, too wide or too painful to push out.

o put off pooping. A child may be too busy playing and not want to stop.

o change in activity or daily routine

o change in diet

o certain medicines

• Constipation is often temporary, easy to prevent, and easy to treat if you know its causes and signs.

Signs of Constipation

• stomach pain or cramping

• less than 3 bowel movements in a week

• change in how the stool looks – hard, dry little logs, sausages, or balls

• blood on the surface of hard stool

• unusual pain when pooping

• fecal soiling – finding traces of poop in your child’s underpants. This may be a sign that their stool is backed up in the rectum.

• child hiding in the corner of a room or suddenly becomes very quiet and still when playing or talking

What to Do

• Retrain your child’s body to have regular bowel movements. If your child is toilet trained, work with them to make going to the bathroom a regular habit. Choose the same time every day and follow the same routine.

o It is best to try after a meal.

o Have your child sit on the toilet for 5 minutes after eating, to try to have a BM.

o Place a footstool under their feet so they do not dangle. Tell your child to lean forward.

• Try to stay calm and not be too concerned if your child does not have a BM. Let them try again later in the day.

• Look at the stool each time so you know what is normal and not normal for your child. The stool should be soft, like mashed potatoes.

• Have your child drink diluted 100% fruit juice. A serving of prune juice or prunes once a day may help.

• Teach your child to come in from play every time they have the urge to poop.

• Encourage them to be active by playing instead of sitting.

• If these things do not work, ask your health care provider to recommend an over-the-counter (OTC) medicine. Be sure to find out the right dose for your child, when to take, and for how long. OTC medicines for constipation often do not have this information on their label.

• To help prevent constipation, give your child foods high in fiber, like whole grain cereals, breads, fruits, and vegetables. Encourage them to drink water throughout the day.

What Not to Do

• Never punish your child when they cannot poop or if they have an accident in their pants. They do not do this on purpose. Punishment can stop them from learning good habits.

Rewards

• All children like to be rewarded for doing a good job. Every time your child sits on the toilet long enough to poop, give them a reward. Do this whether they have a BM or not. The reward can be simple, such as a favourite TV show, a favourite chocolate or a sticker.

• Use a calendar or daily record to keep track of their successes..

• After a few weeks, agree on a greater reward for sitting on the toilet. In time your child will get used to going to the bathroom at the same time every day. It will become a habit.

Fecal Impaction, Incontinence, and Soiling

When a child is constipated for a long time, sometimes the stool gets bigger and bigger, stretches the inside of the rectum, and gets stuck. This is called fecal impaction. When the nerves and muscles in the rectum get stretched over and over again, the child may not feel the urge to poop any more. Liquid stool can leak around the harder, backed-up stool (incontinence) and seep onto underwear (soiling). It may seem as if the child has stinky diarrhea. When the stool gets stuck like this, your child’s health care provider will need to clean it out. They will work with you on how to prevent your child from having an impaction again. Treatment may take many months.

When to Call the Health Care Provider

Call your child’s health care provider if you see any of the following:

• bright red streaks of blood in the stool

• no bowel movement for 3 days

• pain in the stomach or rectum along with constipation

• vomiting, constipation, and your child’s belly looks bloated or filled with gas

• fecal soiling or accidents in their pants

Constipation (con-sta-PA-shun) in infants can worry parents. Most of the time, your baby is not really constipated. They may not have developed a routine for pooping yet. Some babies do not develop a bowel movement (BM) pattern for a while.

An infant’s BM pattern can change if their diet changes, like switching from breastmilk to formula, starting solid foods, or drinking less formula than usual. If your baby’s stool (poop) is not soft or easily passed, then they may be constipated.

In rare cases, constipation may be caused by a lack of nerves going to the intestines or by a problem with the way the intestine formed at birth. Your baby can be tested for these conditions if your health care provider feels it is needed.

Signs of Constipation

• less stools than their usual pattern

• straining more than normal to have a bowel movement

• a change in how the stool looks from soft and mushy to:

o small, hard pebbles, or like a large, round golf ball

o loose and watery

• abdomen (belly) bloated or swollen with gas

• painful cramps

Treatment

• If your baby is not eating baby food yet, you may give 30 to 50 ml of 100% fruit juice (pear, prune, cherry, or apple) once a day. Stop the juice if their stools become too loose.

• If they are old enough to eat baby foods, feed them pureed pears, peaches, or prunes instead of giving them juice.

• If your baby eats cereal, it may help to give oatmeal, wheat, or barley cereal. Rice cereal can cause constipation in some children.

• Sometimes giving your baby a warm bath to relax them or exercising their legs, like riding a bicycle, will help stimulate the bowels to move.

• If it has been a few days since your baby has pooped and the juice or pureed food has not worked, then you can try a glycerin suppository. Place your baby on their back. Gently push the suppository into their anus (bottom). Suppositories are meant for occasional use.

• Contact your baby’s health care provider before giving them laxatives, baby mineral oil, or enemas to treat constipation.

Medical Therapy

Your child’s health care provider may order the following treatments:

• Give your child medication.

• Check your child’s temperature using a digital, rectal thermometer. Put a small amount of petroleum jelly (Vaseline®) on its tip before inserting into the rectum. Taking a rectal temperature may stimulate the baby to pass stool.

When to Call the Health Care Provider

Call the health care provider if any of the following occurs:

• Your baby is irritable and seems to be having stomach pain. Infants will pull their legs up to their stomach and cry when they are in pain.

• Your baby has constipation and develops vomiting, and their belly looks like it is bloated or filled with gas.

• You see blood in their stool.

• Their constipation does not get better with treatment.